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Managing mental
illness in the dialysis
treatment environment:
A team approach
MEGAN PRESCOTT, MSW
Abstract
Outpatient chronic hemodialysis
facilities often serve large popula-
tions of patients in an open and
sometimes fast-paced environment.
Any sizeable group of people will
contain a sample of mental illnesses
—and the end-stage renal disease
diagnosis can be accompanied
by co-occurring or comorbid men-
tal illness. Thus, it is important for
professional teams to be able to
effectively manage related issues
arising in the dialysis clinic. Guided
by Medicare mandates, dialysis clin-
ics all employ a masters level social
worker to respond to the myriad
psychosocial needs of this popula-
tion; MSWs are trained to recognize
the signs and symptoms of mental
illnesses, and can help guide the
team response.
At the time this article was written, Ms. Prescott was
a clinical social worker with the Renal Center at St.
Joseph Hospital, Orange, Calif. She is currently with
Fresenius Medical Care in Denver, Colo.
32 Nephrology News & Issues • December 2006 www.nephronline.com
SOCIAL WORK
Introduction some mental illnesses (depression) from restrictions and recommendations, and
The National Institute of Mental their dialysis clinic social worker. The often manage numerous medications.
Health estimates that 22.1% of American trust and relationship established with Mental illness can influence both motiva-
adults (aged 18 and older) fit the cri- their nephrology social worker appears tion and ability to manage the complexi-
teria for a mental disorder in a given to improve the odds they will seek needed ties of the treatment regimen.
year. According to NIMH data, the most treatment when compared to services Despite the many challenges, the dial-
commonly diagnosed are depressive available from a mental health provider ysis treatment setting—where patients
and anxiety disorders. Close to 10% of in their community. are typically seen in the clinic three times
American adults (over 18 years of age) a week—provides an almost ideal envi-
have a depressive disorder within a given The dialysis environment ronment to monitor changes in mood,
year, while a slightly higher percentage The dialysis treatment environment affect, behavior, and mental status in
(13.3% of adults age 18-54) are diagnosed presents unique challenges to the man- patients with co-occurring mental ill-
each year with an anxiety disorder.1 agement of patients with mental illness. ness. The presence of a team member
The incidence of mental illness in the The presence of a mental disorder can hin- who is trained to recognize key indicators
dialysis environment could be higher, der patients’ adaptability to the dynamic and guide intervention can help improve
as studies indicate that ESRD patients treatment environment. Small changes in treatment potential for these patients.
experience depression more frequently the structure of treatments—like sched- The ultimate goals for managing men-
than adults in the general population.2,3,4
One recent study suggested that 44% of …the majority of dialysis patients prefer to seek
patients in the early stages of dialysis
treatment met the criteria for depression.5
and receive treatment for some mental illnesses
The dialysis sample is also older than the (depression) from their dialysis clinic social worker.
general population, and therefore may
present with more incidence of dementia, ule times or seating assignments—can be tal illness in the dialysis facility include
related and unrelated to ESRD. particularly upsetting to some. In com- keeping the staff and other patients as
Although it has not been thorough- parison to other medical consultation safe and comfortable in the treatment
ly examined, most providers report an and treatment environments, outpatient environment as possible, minimizing dis-
increase in the number of patients admitted hemodialysis provides less privacy for ruptions, and maximizing treatment out-
to the dialysis clinic with ESRD secondary discreet discussion, complicating man- comes for all patients.
to cocaine, heroin, or methamphetamine agement of personal matters and issues
use. One study confirms the often hidden between patients and providers. Team preparation
incidence of drug-related renal failure.6 Direct patient care staff members in Lack of training in recognizing and
In the United States, mental illness- the dialysis setting are chiefly trained to responding to mental disorders creates a
es are diagnosed based on criteria set provide dialysis treatments and manage particular challenge for dialysis staff. In
forth by the Diagnostic and Statistical the patient medically. They often request the busy dialysis environment, there is a
Manual, currently in its 4th Edition, Text more support and training in responding tendency for team members to grow frus-
Revision (DSM-IV-TR). In this manual, effectively to patients with mental illness. trated with challenging patient behav-
each mental illness has a set of diagnostic Angella Perez, CHT, a patient care techni- iors, and to react to signs and symptoms
criteria, details about commonly associ- cian, states, “With dialysis patients, we of mental illness in a defensive way. It is
ated features, and demographic data such are dealing with a whole varied list of common for the team to interpret these
as prevalence in the population, genetic problems and not all of them are related patients as “difficult” or “manipulative,”
patterns, age, and gender trends, etc.7 to the kidneys or other medical prob- when in actuality they are seeking to meet
Masters level social workers are among lems. Mentally ill patients can be a huge their needs in the only way they know. In
the professional groups—which include challenge. Sometimes minor details that addition to being ineffective, these types of
psychiatrists, psychologists, counselors, most patients find insignificant can be punitive responses can exacerbate prob-
and other mental health professionals— very important to the patient with men- lematic patient behaviors and potentially
trained to recognize indicators of mental tal illness. It is important to stay sensitive damage patient/staff relationships. The
illness as defined by the DSM, and can to that.” clinic team social worker, who is trained
serve a unique role on the renal team in The dialysis treatment regimen is also to recognize and respond to mental dis-
helping to manage these patient issues complex, and requires the patient’s active orders and altered mental status, can
in the dialysis setting. In fact, studies participation for the best outcomes. consult with the team to respond to these
show that the majority of dialysis patients Patients must follow a strict treatment patient behaviors in ways that will actu-
prefer to seek and receive treatment for schedule, adhere to complicated dietary ally help the patient learn more effective
www.nephronline.com December 2006 • Nephrology News & Issues 33
SOCIAL WORK
ways of managing their needs in the dialy- dementia to depression.2,8 A recent study helping maintain patient self-esteem, and
sis clinic. In team care planning meetings, showed as much as 30% of sampled dialy- encouraging continued interest in under-
social workers can play a pivotal role in sis patients were cognitively impaired, a standing matters regarding their care,
identifying where mental illness is a bar- figure much higher than the general pop- despite cognitive limitations.
rier to clinical outcomes, psychosocial ulation.8 Other studies connect cognitive All members of the team should take
functioning, and appropriate behavior in limitation with low nutrition scores and a similar approach with treatment struc-
the dialysis environment. They can then increased hospitalizations. Clearly, clini- ture to avoid confusion. This will instill
help guide the team response to stabilize cal outcome determinants in the ESRD a sense of routine, and reduce poten-
patient behavior in these areas. These population are a blend of medical and tial for anxiety and agitation. Cognitive
social work activities can build team skill psychological strengths and risk factors.9 impairment could be most evident dur-
and confidence in managing the mentally ing dialysis treatment, reducing the value
ill patient, which in turn will communi- Recommendations of educational efforts while the patient
cate optimism to the patient and relax Dementia will obviously have an is dialyzing. Depending on the patient,
the treatment relationship. adverse effect on a patient’s ability to instructions should be given before or
This article will now review several of understand the treatment routine and after dialysis whenever retention is a con-
the most common mental illness diagno- manage the intricacies of dietary adher- cern, and written down for later review.
Patients with dementia have a tendency
to ask redundant questions or require
Practice patience; a constant reassurance. It can be helpful to
answer repetitive questions and respond
calm, compassionate to preservative thoughts the same way
approach can help each time; this practice can be extended
increase comfort through the team by rehearsing a “script”
with all involved staff. It is likely that
with the treatment patients with dementia will demand more
environment and time from nurses and technicians in the
dialysis clinic. Staff members should
strengthen the patient/ expect that explanation and repetition
provider relationship. will be part of the treatment protocol for
these patients.
Practice patience; a calm, compas-
sionate approach can help increase com-
fort with the treatment environment and
strengthen the patient/provider rela-
tionship. A rotation of team members,
even during each dialysis treatment, can
reduce the risk of team frustration and
ses presented in the dialysis clinic envi- ence and medication management. It is burnout with these patients. If patient
ronment, and make recommendations important to ensure that each staff mem- behaviors reach a point of disruption,
for team management. ber is in contact with a designated care- the social worker can team up with the
giver to communicate all progress reports nephrologists to pursue a brief stay in a
Dementia and new instructions. Care logs that trav- mental health unit of an acute hospital to
With a steadily aging ESRD popu- el between caregiver and the renal team pursue psychiatric evaluation and inter-
lation—more than 50% of patients on (via the patient) can help to coordinate vention. This brief stay can provide medi-
dialysis are now over age 65—the inci- treatment changes and other informa- cation changes that will allow a patient
dence of dementia will likely continue to tion. Regular care planning telephone suffering from dementia to continue on
rise, including mental impairment from calls between skilled nursing, extended dialysis therapy.
Alzheimer’s disease, vascular dementia, care, or day treatment facilities can help Social work skills should also be uti-
and altered mental status from other maximize overall treatment outcomes in lized to provide the renal team with
causes.2 The dialysis population has the cognitively impaired patient. With information and support regarding fam-
elevated risk factors for stroke associ- regard to patient management, involv- ily decision making in these cases. Renal
ated with hypertension and diabetes, and ing the patient directly can be helpful by team members can grow confused and
some data now links elevated risk for keeping the patient engaged with staff, frustrated in deciding to continue dial-
36 Nephrology News & Issues • December 2006 www.nephronline.com
SOCIAL WORK
ysis for a patient with dementia that occurs in up to 40% of ESRD patients.11 The inadequacy, hindering their motivation to
requires this level of management. Social distinction between psychological distress become partners in their treatment. It is
work consultation can assist the team in and clinical depression is an important important for the team to recognize that
understanding the developmental family one. When a physician or renal team mem- a patient who is depressed is likely to need
dynamics that lead to these decisions, so ber remarks, “Of course s/he is depressed, persistent, compassionate, and repetitive
that they can approach care with more s/he is on dialysis!” it is important to point educational efforts. Showing open frustra-
understanding and acceptance. Brief out that between 60%–75% of patients on tion with a patient’s inability to integrate
social work roundtables to discuss pro- dialysis are not depressed. Depression is not important treatment information into
fessional ethics and personal/profession- a “normal” condition for dialysis patients. action will most likely reinforce the nega-
al values can also be helpful to the team It is a serious co-morbid medical illness tive thinking that accompanies depres-
when working with patients suffering that calls for treatment. Depression is eas- sion. Irritability and anger can also occur
from advanced dementia. ily treated in most patients with ESRD, and in patients suffering from depression, and
Social workers can utilize the Mini is likely to improve treatment outcomes.12 be triggered by small upsets. Learning to
Mental Status Exam, available through It is important for direct care staff mem- expect this reaction and responding calm-
PAR, (http://www.minimental.com) to bers to understand the physiological and ly can be helpful.
determine the nature and extent of cog- psychological symptoms of depression, An additional task of the renal team,
nitive dysfunction, and measure improve- how these symptoms interplay, how they when working with depressed dialysis
ment or decline over time. This informa- can affect a patient’s engagement in the patients, is to carefully assess when com-
tion can be used to inform the team how dialysis treatment regimen, and how they ments are made regarding “giving up” or
to better relate to the patient and can may relate to the renal team. Depressed terminating treatment. Withdrawal from
help determine the need for increased patients can experience difficulty with dialysis is not uncommon, occurring in
team support and treatment planning. concentration, which can affect their abili- nearly 20% of dialysis patients before
The prevalence of dementia in the ty to absorb and integrate education about their death.10 To dialysis professionals,
dialysis population also points toward the treatment regimen. Cognitive changes this is not typically interpreted as a sui-
the importance of early discussions with can leave patients suffering from depres- cide, but as a rational decision in line with
patients and families about the benefits sion with feelings of hopelessness and a patient’s rights to self-determination.
and rationale of advance directives. It
is difficult to develop meaningful doc-
umentation of advanced planning and
personal health care preferences once a
person’s ability to understand the process
and implications is impaired; an early
education effort is recommended for all
patients, as cognitive impairment could
progress over time on dialysis.2
Depression
Depression is the most common psycho-
logical problem among dialysis patients,
and is becoming a more prevalent topic in
the literature due to growing understand-
ing of its link to increased mortality.10 The
dialysis social worker can be useful in help-
ing the team to identify clinical depres-
sion and differentiate the symptoms from
those of uremia, which can appear quite
similar. Lack of energy, low appetite, and
difficulty sleeping are present in both, and
can confuse the clinical picture, especially
in patients new to dialysis when both are
most likely to be present. While “distress”
is a nearly universal experience in patients
with ESRD from time to time, depression
www.nephronline.com December 2006 • Nephrology News & Issues 37
SOCIAL WORK
However, when a patient who desires to managing medication to control bi-polar Such regular discussions may help fos-
withdraw from dialysis is clearly suffer- symptoms) could help provide better con-ter a better understanding among direct
ing from clinical depression, it is reason- tinuity of care. care staff about the impact of depres-
able to evaluate whether the symptoms Members of the renal team can be sion on dialysis patients in both adjust-
of depression are treatable before the trained to alert the social worker when ment and chronic stages. Social workers
decision is acted upon. These symptoms patients present with mood changes, can provide patients with psycho-educa-
can contribute to perceptions of “energy” offering a protective system of surveil-tional support to facilitate understanding
and a sense of “hopelessness” about the lance for patients with this disorder. of their symptoms, as well as cognitive
future, and can influence a patient’s will Simple questions such as, “Over the pastbehavioral counseling to combat negative
to live. Treatment, with medications or four weeks, have you felt so down in thinking and increase enjoyable activities
psychotherapy, or both, can significantly the dumps that nothing could cheer you and social contacts. These interventions
improve a patient’s ability to cope with up?” and “Have you felt downhearted have been found to improve both mood
chronic medical illness and thus, should and blue?” have been shown to predict and patient satisfaction with care in the
be encouraged prior to decision- dialysis clinic.16
making regarding termination Patients started on antide-
If the anxiety disorder
of treatment. Consideration of a pressant medication can benefit
patient’s right to self-determina- is not medically treated, from educational support to pro-
tion, medical complications, fam- and patients become mote better adherence. A social
ily support, perceived quality of work case management model
life, potential for clinical improve- over-adrenalized, they can be effective when medica-
ment, and other factors will play enter a biochemical, tion is prescribed by a primary
a part in this highly personal care physician or psychiatrist to
and individualized decision.13 parasympathetic “fight ensure remission of symptoms
Literature suggests that major or flight” reaction… within the first 12-week phase of
depression for the dialysis patient treatment.
can become a downward spiral in
complex, emotional, and physical Anxiety disorders
ways, and can increase mortality Unlike normal anxiety that is
by staggering percentages.14 a part of everyday life, in the
Another type of depression, form of stress and worry, anxi-
known as manic depression or ety disorders are disruptive and
bipolar disorder, is typified by dis- overwhelming. Anxiety disorders
creet periods of depression and can be caused by a variety of fac-
mania. Bipolar disorder is suc- tors, alone or in combination,
cessfully treated with medication, though depression and to be a valid first-line including genetics, changes in the brain,
adherence to mood stabilizing medica- screener of depression.12 Screening ques- or environmental stressors. A major med-
tions for bipolar symptoms can be prob- tions such as “Recently, have you not felt ical crisis can be a contributing factor
lematic, especially during manic phases. like your usual self ?” or “Have thoughts in the onset or exacerbation of an anxi-
ESRD patients with bipolar disorder in raced through your head or have you had ety disorder. Anxiety symptoms are also
either depressed or manic phases will have difficulty slowing your mind down?” can common features of major depression,
difficulty managing dialysis demands, be taken from public domain measures and an assessment should determine the
and careful consideration of adherence and used as simple screeners to alert the primary source of the symptoms. Patients
patterns is important for transplant can- team of the need for further evaluation with anxiety disorders are faced with the
didates. Social work interventions can be (www.dbsalliance.org/survey). daunting task of learning to function in
utilized to improve medication manage- a busy medical treatment environment
ment and monitor for mood swings. Due Recommendations that may cause them considerable emo-
to a high incidence of co-occurring drug/ When symptoms of depression are tional distress while offering little time
alcohol dependence, the social worker present, the social worker should be for team reassurance. If the anxiety disor-
should also monitor for signs and symp- referred to do a thorough assessment and der is not medically treated, and patients
toms of substance abuse. With consent evaluate clinical risks. Team meetings become over-adrenalized, they enter a
from the patient, maintaining contact can be the ideal place to discuss patient’s biochemical, parasympathetic “fight or
with the primary care physician or psy- depressive symptoms, and the impact flight” reaction, and present to staff as
chiatrist (whoever is most involved in on adjustment or treatment outcomes. “demanding” or disruptive. They can
38 Nephrology News & Issues • December 2006 www.nephronline.com
SOCIAL WORK
suddenly seem inappropriate or use foul own issues and behaviors, consistently on others creates a nearly impossible
or loud language. These behaviors can identifying problems as stemming from challenge for them. It is advisable for
be involuntary and internally driven to other people and situations. This rigid social workers to meet with the treat-
reduce a state of physiological stress. pattern of perception and behavior can ment team upon admission and on a
Anxious patients often feel shame fol- present the renal team with great chal- regular basis to maintain team confi-
lowing these sudden disruptions, and lenges in terms of managing their own dence and skill in working with dialy-
they can impact interpersonal relation- professional reactions and personal feel- sis patients that suffer from personality
ships, including those with the treatment ings in the dialysis clinic.17 disorders. It is also helpful for the social
team. The team can be helpful to the worker to examine adherence behavior
patient when responding with concern Recommendations and work with patients to maximize their
for them and seeking to understand what Although mental health treatment of skills for adherence, given their difficul-
they need in that moment. This usually personality disorders has grown more ties with rigidity and impulsivity. If, his-
diffuses the situation quickly and restores promising,17 the renal team must remem- torically, the patient has demonstrated
trust in the treatment relationship for ber that the disorder is most likely long- difficulty, and they are not responsive to
both the patient and team member. standing, and change in behaviors associ- skill building, transplant candidacy may
ated with the disorder are slow to occur. be compromised.17
Recommendations
For patients suffering from an anxi- Other common mental illnesses
ety disorder, including generalized anxi- Other mental illnesses are likely to
ety, panic disorder, phobias, obsessive- Social workers can emerge in the ESRD population, but are
compulsive disorder, and post-traumatic not well represented in the literature.
stress disorder, small changes can bring help the patient These include substance abuse disorders,
big distress. It is important to take time schizophrenia, eating disorders, attention
to explain any changes in the treatment
process their deficit hyperactivity disorder, and oth-
plan. For patients with a known pat-
tern of anxiety responses, social workers
response and create ers. Social workers can consult with and
assist staff as issues arise, as well as pro-
can partner up with the team to inform a strategy to tolerate vide patients with resources and counsel-
patients of changes to schedule or seat ing to maximize their adjustment and
assignments. Social workers can help the the change. outcomes in the dialysis environment.
patient process their response and cre-
ate a strategy to tolerate the change. If General guidelines for working with
choices can be offered, the social worker dialysis patients with mental disorders
may help the patient feel more in control Due to the nature of the disorder, it is With patients formally diagnosed with
of and capable of tolerating the change. likely that the same types of behaviors or exhibiting symptoms of mental illness,
A thorough assessment for the presence and problems will occur over and over it is important to keep communication
of phobias in new patients is important, again in the dialysis clinic. The renal open between team members. Cohesive
especially needle phobia or claustropho- team should work together to compose team efforts must be made to maintain
bia, both of which are likely to be particu- a professional strategy and response to a trust between the patient and the treat-
larly challenging for dialysis patients. recurring situation to avoid burnout and ment team. These patients are likely to
team stress. It is critical for the team to experience the dialysis clinic environment
Personality disorders keep communication open at all times to as one of the greatest challenges to living
Given the prevalence of personality avoid team division or “splitting” (partic- with mental illness. It is imperative to
disorders in the U.S. (10%-15% of adults ularly in cases of borderline personality maintain professional composure in the
fall into one of the 10 formal categories), disorder). Teams can rehearse responses face of behavioral problems from patients
the likelihood of encountering personal- such as, “Mr. Jones, I really want you to with known mental illness, and avoid
ity disordered patients in ESRD treat- feel cared about and comfortable here; “gossip” about these sensitive patient mat-
ment is high.7 These patients will most let’s start again.” These responses can be ters. The social worker and team mem-
likely have difficulty with adapting to very effective in calming the interper- bers should be kept abreast of behavior
new patterns and expectations, and pres- sonal fears and confusion of a patient changes, mood changes, or disruptions
ent with an “inflexible, deeply ingrained with a personality disorder. It can also even if they seem inconsequential. These
style of behaving and responding to situ- help these patients practice more effec- could inform past or future issues by
ations.”17 Most of these individuals lack tive ways of meeting their needs in the painting a clearer clinical picture of prob-
ability to be introspective regarding their dialysis setting, where their dependency lematic behavior and direct, appropriate
www.nephronline.com December 2006 • Nephrology News & Issues 39
SOCIAL WORK
and consistent responses. Prevention of orders in the dialysis environment are Dis. 46(5):919-24, 2005
disruption is a key goal when effectively depression, dementia, and anxiety dis- 5. Watnick S et al. The prevalence and treatment
managing patients with mental illness in orders, and appear far more often than of depression among patients starting dialysis.
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creating fear among those in the clinic, combination of physical and psychoso- and end stage renal disease. Am J Kidney Dis.
but can damage the patient-team rela- cial factors.8 In patients with mental ill- 38(3):523-8, 2001
tionship. Even worse, these can lead to a ness, the psychological factors can bear 7. American Psychiatric Association: Diagnostic
discharge from dialysis clinics, ultimately even more weight in determining treat- and Statistical Manual of Mental Disorders, 4th
preventing access to care for this fragile ment outcomes. ed., text revision. Washington, D.C.: American
population of ESRD patients. Frequent Social workers have an important Psychiatric Association, 2000
and brief team trainings can be provided role in guiding the team management 8. Kurella M et al. Cognitive impairment in chronic
by the dialysis clinic social worker to of mental illness in the dialysis setting. kidney disease. J Am Geriat Soc. 52(11):1863-
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